There was a fascinating plenary session about treatment of thyroid cancer today. And therein lies one of my frustrations working outside of an academic medical center, and in the real world. And in some ways, I feel helpless about it.
My life as a Malaysian doctor in the United States.
Friday, April 23, 2010
We know that for the most part, patients with differentiated thyroid cancer have excellent prognosis. There is also ample published data from my alma mater that adequate surgery is virtually curative in stage 1 and 2 patients; there is virtually no survival benefit of additional radioactive iodine ablation. Hence, the bias I picked up from there is, low risk patients do not usually need ablation. However, the sonographers there are amongst the best in the world, and if there is disease in a node, they call it. And the surgeons do a good job with the surgery. I131 should not be used as a technique to 'clean up' tumor burden left behind by the surgeon because of inadequate pre-op evaluation. I know, this might be a somewhat debated topic, but the 20-year survival data they published is hard to argue against.
Problem is, outside of large centers like that, you realize you have no control over what someone else does before they consult you. And when the endocrinologist is consulted only AFTER surgery, and when they didn't even look at the lymph nodes before and during surgery, you realize sometimes your hands are tied. And if the radiologist has the blatant honesty to say they don't trust their techs to look at the the cervical nodes, even if you could have, how much weight would you put on cervical sonography? (admittedly I'm not sure if they were also motivated financially to suggest a CT scan for all my cancer patients rather than the cheaper ultrasound). Are you really going to take the risk of not ablating that patient?
In that sense, I miss working in an institution where everyone communicates with each other, and are all in agreement of the best plan of care. In the meantime, I guess I can only do my best and hope I'm guiding my patients in the right direction.